1. Shambarger, Maurine MSN, RN, CNS
  2. Snyder, Lori MSN, RN, CIC

Article Content

Problem and Significance

Noting that pneumococcal disease and influenza together are the fifth leading cause of death in the United States among persons aged 65 years or older, the Centers for Medicare and Medicaid Services (CMS), in partnership with CDC and others, have targeted vaccination with their Influenza/Pneumococcal Campaign. US immunization rates for pneumococcal vaccination have increased to 54.1% and influenza vaccination to 66.9% for persons aged 65 years and older in 1999; however, the Leading Health Indicators established by Healthy People 2010 target both of these vaccination rates to reach 90% for this population. CDC recommends that all persons receive a dose of pneumococcal vaccination when or after they reach age 65 and that all persons with unknown vaccination status should receive one dose of vaccine. This vaccination can be given anytime during the year and is generally once in a lifetime after age 65. Likewise, they recommend all persons receive an annual dose of influenza vaccine between October and November, and include persons older than 65 years in the high-priority target group of those at increased risk for complications from influenza. While widely recognized as a noble objective, vaccination of at-risk individuals is problematic for several reasons: overcoming the logistic barriers of patients moving back-and-forth through a complex and fragmented healthcare continuum; bridging the gap of discrepancies between nurses, physicians, and pharmacists about the "ownership" of medication administrationi and, finally, effecting a change in healthcare organizational culture from (1) a Medical model to an interdisciplinary patient-focused model and (2) from acute care to a prevention model.


Purpose of the Project

The purpose of this project was to develop a seamless and consistent system for vaccinating high-risk patients as recommended by the CMS.



The objective of the project was to fulfill our Catholic Health Initiatives value of excellence in our ability to serve the community by vaccinating eligible patients so as to reduce morbidity and mortality associated with vaccine-preventable illness, and to do so in a manner that causes minimal disruption of acute care and provides communication back to the primary care provider and other healthcare providers in the continuum.


Description of Project

The CNS and the infection control nurse undertook development of a process to order, dispense, administer, and document routine Influenza and Pneumococcal vaccine of at-risk patients without the order of a physician.



A small multidisciplinary committee was assembled to consider this possibility. Guidelines and recommendations were reviewed and national practices benchmarked prior to flow-charting the ideal process and developing related documents. Input from medical staff, nurses, and pharmacists was sought along the development process. An attempt at medical staff committee approval resulted in significant concerns with the ability to communicate vaccination within the community, resulting in the overvaccination of the population requiring multiple admissions to institutions. With these concerns in mind, the decision-making process was expanded to include members of the healthcare continuum. Consensus was quickly reached that the good of the patient requires that all members of the healthcare continuum use better communication to achieve the standard desired, including improved use of documentation and technology. Medical staff approval was granted for a pilot project on the medical/oncology unit for patients 65 years and older. Education was conducted prior to launching the pilot.


Outcomes and Evaluation

This is a work in progress. In the first month, prehospitalization or during hospitalization, vaccination was received by 91% (Influenza) and 89% (Pneumovax(R)) of patients. Process problems identified during this early phase are currently being addressed prior to expansion of the pilot to include at-risk patients admitted anywhere in the Medical Center.


Conclusions/ Implications for Nursing Practice

CNS can be successful in changing the culture from a medical model to a multidisciplinary approach to providing wellness services that bridges the gaps in services. The project also demonstrated that as the healthcare continuum becomes more fluid, lessons learned and electronic communication can prevent duplication of services and gaps in care.


Section Description

This year's annual NACNS conference is planned for Orlando, Fla, March 9-12, 2005. Over 300 clinical nurse specialists (CNSs) are expected to attend, and as with past conferences, attendees will also include graduate faculty from CNS programs, nurse administrators, and nurse researchers. The theme of the conference, CNS Leadership: Navigating the Healthcare Environment Toward Excellence, was selected to showcase the many ways CNSs acquire and disseminate knowledge and innovative practices in their specialty areas. Two preconference sessions are scheduled. One session, sponsored by NACNS Legislative/Regulatory Committee, targets information for CNSs interested in understanding the legislative/regulatory process as it deals with the practice of nursing, and will also help build skills CNSs need to engage in the process. The second session, sponsored by NACNS Education Committee, focuses on CNS education issues, and as with the education preconferences of past years, anticipates informative dialogue and much sharing among CNS educators around curriculum design, teaching strategies, and indicators of quality in the curriculum that link to the NACNS education standards to program review and excellence. The conference planning committee is proud and pleased to have Jeanette Ives Erickson, MS, RN, CNA, Senior Vice President for Patient Care Services and Chief Nurse Executive of Massachusetts General Hospital as the opening keynote speaker. She will begin the conference by highlighting the importance of CNS practice on patient safety. The planning committee is equally proud and pleased to have NACNS past-president Rhonda Scott, PhD, RN, Chief Nursing Officer of Grady Health System as the closing speaker. Dr Scott will challenge attendees to use the information from the conference to shape quality care delivered in a safe environment and to advance the profession of nursing through direct care to clients, influencing standards of care delivered by other nurses, and influencing the healthcare delivery system to be to support innovative, cost-effective, quality nursing care. A total of 64 abstracts for podium and poster presentations were selected in addition to graduate student posters. The abstracts address the 3 spheres of CNS practice with a strong emphasis on clinical practice improvements. As you will note from the abstracts published in this issue of the journal, specialty practice areas represented in the abstracts include children, adults, and gerontological patient groups; hospital, outpatient, and home care settings, and community health. In addition, a wide variety of specialty topics including smoking cessation programs, end-of-life care issues, and protocols outlining nursing approaches to improved diabetes, cardiovascular and ventilator management. A number of the abstracts described hospital and healthcare system level innovations that resulted from CNS practice. Collectively, these abstracts reflect the breadth, depth, and richness of CNS contributions to the well-being of individuals, families, groups, and communities. The following abstracts are from those presenters who elected to have their work published in the journal so those who are unable to attend this year's conference can share in the knowledge of the conference. As you read each abstract, consider the talent and clinical scholarship of your CNS colleagues who are advancing the practice of nursing and contributing to improved outcomes for patients and healthcare organizations. You may want to contact individual presenters to network, collaborate, consult, or share your own ideas about these topics. Watch for next year's call for abstracts and consider submitting an abstract for presentation at NACNS's next conference in Salt Lake City, Utah, March 15-18, 2006.